Law and Psychiatry
Performance Validity Testing in Neuropsychology:
Scientific Basis and Clinical Application—
A Brief Review
Performance validity testing refers to neuro-
psychologists’ methodology for determining
whether neuropsychological test performances
completed in the course of an evaluation are
valid (ie, the results of true neurocognitive
function) or invalid (ie, overly impacted by the
patient’s effort/engagement in testing). This
determination relies upon the use of either
standalone tests designed for this sole purpose,
or specific scores/indicators embedded within
traditional neuropsychological measures that
have demonstrated this utility. In response to a
greater appreciation for the critical role that
performance validity issues play in neuro-
psychological testing and the need to measure
this variable to the best of our ability, the sci-
entific base for performance validity testing
has expanded greatly over the last 20 to
30 years. As such, the majority of current day
neuropsychologists in the United States use a
variety of measures for the purpose of per-
formance validity testing as part of everyday
forensic and clinical practice and address this
issue directly in their evaluations. The follow-
ing is the first article of a 2-part series that will
address the evolution of performance validity
testing in the field of neuropsychology, both in
terms of the science as well as the clinical
application of this measurement technique.
The second article of this series will review
performance validity tests in terms of methods
for development of these measures, and max-
imizing of diagnostic accuracy.
(Journal of Psychiatric Practice 2017;23;134–
140)
KEY WORDS: performance validity testing, symp-
tom validity testing, effort testing, malingering,
neuropsychology
The possibility of symptom magnification has long
been recognized in the practice of medicine. In 1912,
Sir John Collie1 wrote of fraud in medicolegal set-
tings, and in 1961 the neurologist Henry Miller
134 March 2017
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
MICHAEL R. GREHER, PhD, ABPP
THOMAS R. WODUSHEK, PhD, ABPP
published an article on the concept of “compensation
neurosis.”2 In 1980, Waddell et al3 described phys-
ical signs to help identify nonorganic explanations
for low back pain, which have since been used to
identify symptom magnification. In 2008, Rogers4
indicated that the concept of symptom magnification
in psychology was initiated by the advent of the
Minnesota Multiphasic Personality Inventory,5
which included scales to detect overreporting of
psychological symptoms compared with a normative
population. These types of scales for measuring
overreporting and underreporting of symptoms,
frequently referred to as symptom validity tests, are
now utilized in multiple psychological inventories
and structured interviews; however, their form and
function are outside the scope of this review.
Although assessing for overreporting of psycho-
logical and physical symptoms is an important facet
of neuropsychological evaluations, an additional
interest among current day neuropsychologists is
the detection of feigned or inaccurately measured
cognitive deficits, such as difficulties with memory,
attention, or executive functions. Efforts to uncover
invalid responding in cognitive testing also have a
long history, with early efforts by André Rey6 in the
1940s resulting in techniques that continue to be
used to this day.
TERMINOLOGY
Over time, a variety of terms have been used to
describe the measurement tools neuropsychologists
use for the purpose of discerning valid versus
GREHER and WODUSHEK: Guest columnists, Departments
of Neurosurgery and Neurology, School of Medicine, Univer-
sity of Colorado, Aurora, CO
Copyright © 2017 Wolters Kluwer Health, Inc. All rights
reserved.
Please send correspondence to: Michael R. Greher, PhD,
ABPP, Department of Neurosurgery, University of Colorado
School of Medicine, 12631 E. 17th Ave, C307, Aurora, CO
80045 (e-mail: michael.greher@ucdenver.edu).
The authors declare no conflicts of interest.
DOI: 10.1097/PRA.0000000000000218
Journal of Psychiatric Practice Vol. 23, No. 2
 LAW AND PSYCHIATRY

TABLE 1. Most Commonly Used Performance Validity Tests (PVTs)*

Standalone PVTs Embedded PVTs

Test of Memory Malingering WAIS-III or WAIS-IV Digit Span: Reliable Digit Span
Word Memory Test California Verbal Learning Test-2: Forced choice
Medical Symptom Validity Test Motor/Sensory Indices: Finger Tapping Indices
Dot Counting Test Wisconsin Card Sorting Test: Failure to Maintain Set
Rey 15-item Test WMS-III or WMS-IV: LM II Recognition score
Victoria Symptom Validity Test WMS-III or WMS-IV: VR II Recognition score

*Data from a survey of 316 neuropsychologists practicing in North America published by Martin et al8 in 2015.
LM II indicates Logical Memory II Recognition of WMS-III or WMS-IV; WAIS-III = Wechsler Adult Intelligence Scale, 3rd
Edition; WAIS-IV = Wechsler Adult Intelligence Scale, 4th Edition; WMS-III = Wechsler Memory Scale, 3rd Edition; WMS-
IV = Wechsler Memory Scale, 4th Edition; VR II = Visual Reproduction II Recognition of WMS-III or WMS-IV.

invalid responding, such as “malingering tests,”
“effort tests,” and most recently “performance val-
idity tests.”7 There were many reasons for these
shifts in terminology but, put simply, in large part
they reflect an understanding of the complexities
involved in determining performance validity and
discussing notions of intent as well as sensitivity to
the negative implications involved in identifying
patients as engaging in “malingering” or “poor
effort” in the course of their examination. As such,
current day neuropsychologists view the term
“performance validity tests” or “PVTs” as providing
an accurate description while avoiding terms that
are potentially pejorative, damaging, or presump-
tuous. For this reason, the authors have used this
term in this series of columns. However, for the
sake of convenience and ease of communication,
occasional references are made to issues related to
“poor effort” or “task engagement,” the meanings of
which are largely synonymous and indicate invalid
test-taking approaches without conclusions as to
intent. Practically speaking, “standalone” PVTs are
tests designed and administered for the sole pur-
pose of determining valid or invalid responding.
They come in both paper/pencil and computerized
form and, at face value, seem to be quite similar in
most respects to other neuropsychological tests,
though they are largely insensitive to brain dys-
function and do not provide measurements of actual
cognitive ability. Embedded indicators frequently
represent “built-in” scores on traditional neuro-
psychological measures (those that measure mem-
ory, executive functioning, and so on) that have
demonstrated a psychometric floor, below which
scores may no longer reflect cognitive difficulty but
instead indicate issues related to effort/task
engagement. Table 1, which is based on the results
of a survey of 316 neuropsychologists practicing in
North America, presents the 6 most commonly used
standalone and embedded PVTs according to this
study. Crucially important to the validation of all of
these measures is the demonstration that per-
formance on these measures is largely unaffected by
various neurological diseases and insults. Most
such measures have been validated in wide-ranging
neurological patient samples, and these inves-
tigations have frequently focused on those with
severe impairment to ensure that the measures and
associated cut scores greatly limit the chance of
false-positive diagnoses of invalid responding.
Although the patient samples vary depending on
the test in question, examples include conditions
such as moderate/severe traumatic brain injury,
multiple sclerosis, epilepsy, stroke, and even early
dementia, among others. Validation of these tests
and their associated cut scores with frank neuro-
logical samples such as these provides an evidence-
based criterion by which to argue that scores below
the established cutoffs are unlikely to be the result
of neurologically based cognitive dysfunction.
JUSTIFICATION FOR PVTs
Despite the early work of Rey,6 until recently most
neuropsychologists largely, though not exclusively,
conceptualized low scores on neuropsychological
testing as indicative of brain dysfunction.9 However,
in recent decades, the neuropsychology literature

Journal of Psychiatric Practice Vol. 23, No. 2 March 2017 135

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

 LAW AND PSYCHIATRY
has shifted significantly with growing recognition of
the clearly demonstrated role that non-neurological
factors can play with regard to performance on
neuropsychological testing. An incomplete list of
these non-neurological factors includes severe emo-
tional distress, sleep disturbance, pain, fatigue, cog-
niphobia (avoidance of cognitively effortful tasks to
avoid onset of or worsening of headache pain), and
medication side effects.10 Additional concerns that
neuropsychologists need to consider in the inter-
pretation of cognitive and PVT results include factors
such as sensory disturbances (eg, a visual field cut),
limited facility with the testing language, and the
possibility of subclinical seizures or other significant
mental status fluctuations during the testing process.
Put differently, neuropsychologists have become
increasingly aware that, although neuropsychological
testing is highly sensitive to brain dysfunction, poor
test results are nonspecific and can arise for a wide
variety of reasons. We have also come to realize that
among these non-neurological causes for low neuro-
psychological test scores are issues such as malin-
gering, poor effort, and insufficient task engagement,
which are more common and more nuanced than
initially considered.
The widespread use of standalone PVTs in neuro-
psychological practice began as 2 factors about cog-
nitive testing gained more attention. First, unlike
traditional medical tests such as blood labs or struc-
tural neuroimaging, neuropsychologists recognized
that obtaining valid test results is reliant upon the
examinee’s full engagement with testing, and this
necessary full level of engagement cannot always be
assumed simply because a provider has encouraged
best effort or the examinee reported providing his or
her best effort. Second, neuropsychologists learned
that clinical judgment is often insufficient to effec-
tively distinguish valid from invalid testing without
these types of objective indicators.9,11 Along with the
growing understanding of the limitations of clinical
judgment as it relates to performance validity, new
attempts to refine early PVTs were undertaken with
the hope of increasing the standardization and
applicability of such measures.12,13 For a review of
these concepts and their history, readers are referred
to a 2001 article by Bianchini et al.14
Not only is it important to improve detection of
response validity, but survey data from neuro-
psychologists suggesting high base rates of insuffi-
cient effort in compensation-seeking cases further
136 March 2017
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
highlight the need for frequent use of PVTs. A 2002
survey demonstrated that neuropsychologists esti-
mated probable malingering or symptom exagger-
ation in compensation-seeking cases to be as high as
40% for certain patient groups.15 In addition, studies
of personal injury litigants, Social Security disability
applicants, military veterans, workers’ compensation
patients, and even certain child populations have
demonstrated increased PVT failure rates reflective
of the impact of motivation on testing. Accordingly, a
2005 position paper by the National Academy of
Neuropsychology discussed the importance of utiliz-
ing at least 1 PVT (then described as a test of “effort”)
within the context of neuropsychological exams being
conducted when issues of secondary gain are pres-
ent.16 In a short time, neuropsychologists came to
recognize that, although issues of dissimulation are
of greatest concern in cases involving known issues of
secondary gain (eg, civil litigation, disability bene-
fits), these same issues are also of concern in patient-
focused care settings when there are no apparent
secondary gain issues present, but just to a some-
what lesser degree. A survey of American Board of
Clinical Neuropsychology–certified neuropsycho-
logists15 revealed an estimated rate of invalid testing
results of 8% in a nonlitigating sample; in another
survey study,17 respondents estimated this failure
rate to be around 10% for their overall practice. To
this end, the official position of the American Acad-
emy of Clinical Neuropsychology is to recommend
near universal application of PVTs in both clinical
and forensic settings through utilization of multiple
standalone and embedded measures.18
INCREASED PVT USE IN CLINICAL PRACTICE
Not surprisingly, the use of at least some form of
PVT has climbed dramatically in forensic and clin-
ical practice. In 2015, Sweet et al19 surveyed
approximately 1500 neuropsychologists across the
United States and found that 99% of practitioners
who do at least some forensic evaluations support
the utility of PVTs, and 98% of providers with no
forensic practice also support use of PVTs. Indeed,
in a 2015 article reporting the results of another
survey of neuropsychologists, Martin et al8 stated
that a “significant paradigm shift” had occurred in
the neuropsychology community over the past
8 years, whereby PVTs are considered mandatory or
desirable irrespective of setting, as endorsed by
Journal of Psychiatric Practice Vol. 23, No. 2
 LAW AND PSYCHIATRY
99.7% of survey respondents. More specifically,
Sweet et al19 found that among providers who do
forensic evaluations, approximately 90% use some
combination of standalone and embedded PVTs in
forensic evaluations and approximately 80% do so
in clinical evaluations; among providers with no
forensic practice whatsoever, approximately 70%
use some combination of PVTs with their patients.
An important consideration for the combination
of PVTs that a clinician may choose to administer is
understanding the sensitivity and specificity or
range of applicability of various indicators.
Although the psychometric quality of embedded
indicators is usually fairly good, they are often less
sensitive than standalone measures and they are
frequently validated using a more restricted pop-
ulation compared with standalone PVTs. Accord-
ingly, the value of failed embedded PVTs is quite
clear when appropriately applied but tends to carry
less weight than standalone tests with regard to a
possible diagnosis of performance invalidity. A
related point is that increasing the numbers of
PVTs in a given battery improves sensitivity to task
invalidity and the presence of multiple PVT fail-
ures, either standalone or embedded, has been
shown to provide improved detection of significant
performance validity issues.20 That said, increasing
the number of PVTs in a given battery also has the
potential to increase the probability of tipping the
scales toward a false-positive diagnosis of failed
performance validity testing, if not appropriately
considered. As will be discussed in greater depth in
the second installment of this series, ongoing neu-
ropsychological research is now providing clinicians
with a better understanding of appropriate deci-
sion-making criteria when utilizing multiple PVTs
simultaneously.
INTERPRETATION OF PVT FAILURES
A substantial and impressive body of evidence on
neuropsychology PVTs obtained over the last
30 years clearly demonstrates that failed PVTs
overwhelmingly occur more often in cases where
there is incentive/secondary gain present (eg,
compensation/disability seeking) than in those
cases in which secondary gain is not present. That
said, an evolving understanding of the complexities
involved in the clinical interpretation of failed PVTs
has also developed. Whereas PVTs were once widely
Journal of Psychiatric Practice Vol. 23, No. 2
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
described and interpreted as “malingering tests,”
the benefit of additional research and theoretical
discussion about this subject has yielded an
increasingly conservative and refined approach to
interpreting performance validity failures. One
example of this refinement is reflected in the 2012
Slick and Sherman update21 of the original 1999
Slick, Sherman, and Iverson criteria22 for diagnos-
ing malingered neurocognitive dysfunction. The
update responded to a number of critiques of the
original criteria that related to both newly gained
methodological improvements in PVT assessment
as well as expanded conceptual and diagnostic
notions of malingering.23–25 In clinical practice, the
frequency of diagnosed definite malingered neuro-
cognitive dysfunction is typically limited to a
minority of individuals who are being seen in for-
ensic settings, with an even lower number in gen-
eral clinical settings. Data from a survey of mem-
bers of the National Academy of Neuropsychology
found estimated rates of probable and definite
malingering at 3% and 1% of cases, respectively,
with only a minority of respondents (29%) indicating
a willingness to make this diagnosis.17 This limited
willingness in part reflects that one of the greatest
challenges to the detection of malingering lies in our
ability to establish the intent of the examinee/
patient to feign symptoms for secondary gain, as
required by the criteria, and indeed some have
argued that determining intent may not be scien-
tifically plausible.26,27 A conservative approach is all
the more important given the potentially negative
impact of a false-positive malingering diagnosis.
As discussed previously, there has also been
increased understanding that factors besides con-
scious intent can negatively impact scores on PVTs,
particularly for examinees in clinical care settings.
Psychological factors such as somatoform disorders/
conversion disorders are certainly a consideration,
if present, as evidenced by a well-established asso-
ciation between psychogenic nonepileptic seizures
and failed PVTs.28 Other psychological conditions
such as depression or posttraumatic stress disorder
are typically not a sufficient explanation for PVT
failure, with issues related to performance validity
or effort being far more likely to account for low
PVT scores in these conditions, with the possible
exception of extreme cases such as those involving
vegetative depression.29 Short of psychopathology,
it has been argued that a patient’s interest in
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 LAW AND PSYCHIATRY
undergoing the evaluation and his or her beliefs
about the fairness of the evaluation and resultant
investment in the testing process sometimes
account for performance validity issues.30 However,
we would note that such explanations for PVT
failure are likely the exception rather than the rule.
It is important to note that the well-informed neu-
ropsychologist has a wealth of PVT research data as
well as case-specific clinical data to rely upon when
attempting to make judgments regarding these
more challenging cases and will of course also need
to consider the possibility of mixed presentations in
which both pathology and invalid responding exist
simultaneously. As demonstrated by the previously
noted position statements and survey data, the
voluminous PVT research of the last 30 years has
provided neuropsychologists with the confidence
that these measures are highly valuable tools that
have greatly increased the value of neuro-
psychological assessment. Continuing research
efforts should push toward ever improving classi-
fication rates and greater guidance regarding more
challenging mixed or ambiguous presentations.
The high frequency use of PVTs across forensic
and patient-focused care settings is not to suggest
that all clinical patients must undergo performance
validity testing irrespective of their clinical pre-
sentation, or that PVT failures should apply equally
across patient groups. Patients potentially suffering
severe cognitive deficits present a particular chal-
lenge for empirical floor PVTs. For example, those
with genuine severe memory impairments are at
increased risk for false-positive findings on certain
PVTs that involve a mild degree of memory
demand. Fortunately, additional PVT detection
strategies such as performance curve discrepancies
can often be used to distinguish these instances of
genuine impairment from invalid responding,
reducing the potential for false-positive errors.31
Like those with dementia, individuals with partic-
ularly low IQs have also been found to be at risk for a
false-positive diagnosis of dissimulation on PVTs,
and clinicians are encouraged to consider this in their
cut-off selection and interpretation of PVT scores.32
In some such instances, “failed” PVTs may represent
a direct function of the individual’s cognitive weak-
nesses. As such, the clinical data acquired in the
course of the evaluation (eg, on attention and execu-
tive and memory functions) may still be reasonably
accurate reflections of those cognitive domains.
138 March 2017
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Nonetheless, the possibility of poor effort in this
patient population should not be overlooked either.
As demonstrated by Chafetz et al,33 the vast majority
of patients with low IQs who were motivated to per-
form well on cognitive testing passed typical PVTs,
whereas patients with similar low IQs who were
potentially motivated to appear impaired demon-
strated a much greater failure rate.
Even with the benefit of consistent PVT failures,
providers should be cautious given the limitations
mentioned above when considering use of the term
“malingering” in a given individual, except poten-
tially on the rare occasion when the evidence for
this is nearly irrefutable. Boone34 suggested criteria
for malingering that include an established history
of consciously false reporting by the patient/exam-
inee, clear indication of secondary gain, and scores
on PVTs well below established cutoffs or even more
significantly, below chance levels of performance
(which many infer demonstrates the intent of the
patient/examinee to purposefully pick the incorrect
answer). Sharland and Gfeller17 found that, in lieu
of diagnosing malingering, 85% of neuro-
psychologists they surveyed described failed PVT
results as representing performances that are
inconsistent with the injury sustained, and 59% to
66% of respondents stated that these cognitive
performances are invalid and that no conclusion
about true cognitive function can be drawn. How-
ever, 81% of respondents also indicated a willing-
ness to state that test results suggest exaggeration,
and 23% endorsed use of language to suggest that
test results indicate malingering. A more recent
survey suggested a shift in this practice in recent
years, with 82% to 91% of respondents endorsing
interpretation of failed PVTs as indicative of test
results being inconsistent with the severity of
injury, that no firm conclusions can be drawn, or
that test data are invalid.8 Only 65% of respondents
endorsed using language suggesting that test
results indicate exaggeration, and only 11% of this
same sample endorsed use of language suggesting
that test results indicate malingering. These find-
ings confirmed the authors’ sense of a trend toward
utilizing PVT results in most instances to help
establish the validity (or lack thereof) of the cogni-
tive test data which make up the bulk of the
examination process. Irrespective of the explan-
ation provided for failed PVTs, it should be under-
stood that once a performance validity issue is
Journal of Psychiatric Practice Vol. 23, No. 2
 LAW AND PSYCHIATRY
identified, clinical test scores (eg, those on tests of
attention and executive and memory functions)
which fall in the “impaired,” “deficit,” or “deficient”
range can no longer be considered interpretable
because it remains unknown whether those scores
are a reflection of actual cognitive difficulty, insuf-
ficient effort/task engagement, or some combination
thereof. In contrast, scores that fall in the normal
ranges of performance are typically regarded as
reasonably interpretable as a basal level of cogni-
tive ability, though even these “normal” scores may
be an underestimate of actual cognitive functions.
Ultimately, the outcome in such instances is to
severely limit the neuropsychologist’s ability to
make conclusions about the examinee’s cognitive
status. In clinical cases, this in turn limits the
provider’s ability to offer recommendations to the
patient or the referring physician with regard to
cognitive issues (eg, cognitive rehabilitation).
PVT DISCLOSURE
Finally, on the topic of whether to introduce
patients to the notion that PVTs will be adminis-
tered, Sharland and Gfeller17 found that only 22%
of respondents do so. More recent data from Martin
et al8 indicated that 38% of respondents provide a
warning about PVTs. Although this represents an
increase, this approach is still only practiced by a
minority of providers and probably with good rea-
son. A review by Youngjohn et al35 suggested that
doing so does not actually improve effort but simply
makes those providing insufficient effort more dif-
ficult to identify. Instead, the authors recommend
asking examinees if there is anything impeding
their ability to answer questions accurately to the
best of their ability besides their cognitive issues,
and encouraging them to give their best effort.
Although there is certainly room for discussion on
the merits of introducing PVTs at the outset of
testing to examinees, as a general rule the authors
tend to err on the side of caution in this regard and
heed the warnings of Youngjohn et al,35 in an effort
to maximize the probability of valid test results.
CONCLUSIONS
Over the last few decades, the field of neuro-
psychology has gained a far greater appreciation for
the critical role that performance validity issues
Journal of Psychiatric Practice Vol. 23, No. 2
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
play in the course of neuropsychological evaluation.
We have come to understand our inability to accu-
rately detect issues of reduced effort/task engage-
ment without appropriate measures, and the
frequency of this issue in both forensic and clinical
contexts. Accordingly, performance validity testing
has been a significant area of growth and develop-
ment from both a research and clinical perspective
and is now strongly recommended by leading
national associations in the field. The authors’ own
experience is that physicians are increasingly
aware of this trend, as reflected by referral ques-
tions to neuropsychologists in which concerns about
performance validity are being considered. Many in
neuropsychology accept this as part of the neuro-
psychologists’ clinical role in light of the significant
advances made in neuropsychology PVT science
over the last few decades. Indeed, this focus in
neuropsychology over recent years has created a
substantial evidence base for making these deter-
minations, distinguishing the field in the world of
health care. Nonetheless, neuropsychologists will
continue to push for even finer refinement in
research and clinical practice moving forward.
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